A Pediatricians' Raw Experience in Private Independent Medical Practice on the front lines.

Wednesday, July 27, 2016

Rural Care: A Primer For Washington Officials, Columnists and Economists.

Earlier this week,
physicians in small private practices and rural areas breathed a collective
sigh of relief.There is a possibility
the implementation of changes to physician reimbursement (known as MACRA) could
be delayed.Thank you, Mr. Slavitt, for
listening.I am grateful to Orrin Hatch
(R-UT) and Ron Wyden (D-OR) for keeping our rural needs in mind.We have a window of opportunity for rural health
care to survive but we must communicate our needs as physicians and patients’ loud
and clear.

Whether in
reference to health care or public education, trying to increase quality while
simultaneously decrease costs is an unrealistic proposition. Physicians in rural
areas simply have fewer resources at their disposal.Adding insult to injury, Medicare payments to
rural physicians are dramatically less than those of their urban counterparts
for equivalent services, a point driven home by the fact 470 rural hospitals
have closed in the past 25 years.Does
it cost less to stitch up a laceration in a remote Alaskan village than in New
York City?I doubt it.The expenses incurred obtaining supplies may
be even greater for remote locations.

In order to set
primary care physicians up for success, it is imperative those in charge
understand our challenges.Rural
physicians are alone, save for our spouses running our medical practices while
we see patients.For physicians to be
successful, additional revenue would be necessary to meet the expensive health
IT burdens placed on us by this new payment model.Creating “virtual” groups to consolidate
reporting will still require provision of a “virtual” assistant because it is
more administrative burden than we can handle.Our profit margin is too narrow to accommodate additional employees.

I am not convinced time
and money spent implementing new technology does anything to improve patient
care; I am fairly certain, however, conversations with my patients provide
considerable value.Can you not extract
the information from claims, like private insurance companies already do?If we have to hire an additional employee,
who is going to pay them? The solution is relatively simple; shift the burden
of data collection from small practices to elsewhere or
increase reimbursement so meeting your demands becomes feasible.

Preserve what we
have in rural America until you have more clarity where we are heading in the
future.According to a report on Rural Participation
in the Medicare Shared Savings Program, rural providers already deliver value
and quality within our existing infrastructure.Adjusted for lower volumes, Medicare spending per beneficiary is 3.5%
less.Physician spending is 18.4% lower
overall compared to our urban peers. We have strong personal relationships with
our patients, operate at the top of our capabilities, and keep care local whenever
possible. I fail to see the problem with
our old-fashioned style of practice. In fact, maybe you should use us as models
of efficiency or cost-containment for larger conglomerates.

Being in a small or
rural practice is extremely challenging.In rural America, 75% of exchange consumers had incomes less than 250%
of the federal poverty level.Every
family in my practice who obtained insurance through exchanges met criteria for
Medicaid, known in Washington State as Apple Health.24% of rural
children live in poverty.We are surrounded
by Health Professional Shortage
Areas (HPSA’s)and Mental Health Professional Shortage Areas because primary
care physicians are spread entirely too thin.The elderly and poor in rural
areas deserve access to quality health care.What happens to
those people if small practices cannot keep their doors open as a result of
overreaching government mandates?

According to the National Rural Health
Association, 10% of physicians practice in underserved areas despite the fact
25% of the population lives there.One-third of automobile accidents occur in rural areas, however two-thirds
of the deaths from these accidents occur on rural roads.Rural residents are more likely to die from
injury due to delays in care.I have
direct experience, recently providing road side care after an accident while awaiting EMS arrival for 15 minutes. Delays are related to increased travel distance and
personnel limitations.

Extrapolate for a moment what could
happen if numerous small practices closed in rural areas.Can you imagine if one third of strokes occurred
in rural areas, but two-thirds of stroke deaths were rural due to significant delays
in receiving timely treatment?It makes
no sense to cripple our livelihood when we provide lifelines to underserved and
disadvantaged populations.

Rural residents have
fewer resources, significant geographic obstacles, and the acuity level of their
medical problems is far greater.These detrimental
conditions drive tremendous health disparity.We need to spend our time healing, comforting, and having conversations
with patients, instead of reporting their medical problems and immunization
status to non-physician statisticians.

For physicians in small or rural
practices with scarce resources and deteriorating infrastructure, it will
require significant investment for us to undergo meaningful transformation.Either learn more about the challenges small or rural practices
face, provide waivers (like No Child Left Behind did) for exemptions, invest in
our infrastructure, or leave solo physicians and our practices alone.Do not try to fix what I am not convinced is
broken.